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date: 16 October 2019

Frameworks for Priority Setting in Health and Social Care

Summary and Keywords

Health and social care organizations work within the context of limited resources. Different techniques to aid resource allocation and decision-making exist and are important as scarcity of resources in health and social care is inescapable. Healthcare systems, regardless of how they are organized, must decide what services to provide given the resources available. This is particularly clear in systems funded by taxation, which have limited budgets and other limited resources (staff, skills, facilities, etc.) and in which the claims on these resources outstrip supply.

Healthcare spending in many countries is not expected to increase over the short or medium term. Therefore, frameworks to set priorities are increasingly required. Four disciplines provide perspectives on priority setting: economics, decision analysis, ethics, and law. Although there is overlap amongst these perspectives, they are underpinned by different principles and processes for priority setting. As the values and viewpoints of those involved in priority setting in health and social care will differ, it is important to consider how these could be included to inform a priority setting process. It is proposed that these perspectives and the consideration of values and viewpoints could be brought together in a combined priority setting framework for use within local health and social care organizations.

Keywords: health economics, ethics, law, decision science, priority setting, integration, scarce resources

Introduction

This article explores different perspectives to aid resource allocation and decision-making in local U.K. health and social care organizations in the context of limited resources, and what these perspectives may suggest about a robust process for priority setting. Having a priority setting process is vital, as scarcity of resources in health and social care is inescapable. Healthcare systems, regardless of how they are organized, must decide what services to provide given the resources available. This is particularly clear in systems funded by taxation (such as the UK system), which have limited budgets and other limited resources (staff, skills, facilities etc.) and in which the claims on these resources outstrip supply. Solutions to this problem include management of staff costs through contractual reform, reduction of waste and inefficiency, or waiting lists for patients to access treatment. Another solution is to set up national health technology assessment (HTA) bodies like the National Institute for Health and Care Excellence (NICE) in England, the All Wales Medicines Strategy Group (AWMSG), and the Scottish Medicines Consortium (SMC) to make recommendations about the provision of medicines and treatments. However, when HTA agencies recommend new treatments, those at a local level must consider how these new treatments will be funded and decide on the balance of other services provided within their resource-constrained environment.

Adding complexity to such decisions is the move, internationally, toward greater integration of health and social care. Integration, it is argued, should reduce budgetary boundaries and facilitate sharing of resources across health and social care. But in practice integration has proved to be very challenging. While different approaches to integration will be taken in different countries, in a U.K. context integration is embodied in the Health and Social Care (Reform) Act (Northern Ireland) 2009, the Health and Social Care Act 2012 in England, the Social Services and Well-Being (Wales) Act 2014, and the Public Bodies (Joint Working) (Scotland) Act 2014. Within this integrated context, there is a move to alter the balance of care from acute settings to people’s own homes or similar community environments. To facilitate this shift, there is a need to use robust processes for allocating resources to make difficult decisions about which services to fund and to what extent, and to identify which existing services to scale back. With no increase in spending on health and social care likely in the short or medium term, this will be done by shifting resources to services which provide more benefits for the money spent, and will involve disinvestment in services which do not provide as much (relative) value for money; all of this must be subject to equity considerations.

This article provides a brief overview of healthcare spending in the United Kingdom (which is taken as an exemplar for the purpose of discussion), then considers perspectives on priority setting from four disciplines: economics, decision analysis, ethics, and law. Although overlap and similarities exist between each of the perspectives which contribute to priority setting, they are generally reported on separately in published literature, and usually focus only on health settings. There are examples of economics and ethics having been used together. However, they were not used simultaneously or as a combined approach (Gibson, Mitton, Martin, Donaldson, & Singer, 2006). Also, another study looked to combined economics and decision analysis techniques, but there were no ethical or legal consideration incorporated (Peacock, Richardson, Carter, & Edwards, 2007). Another consideration for setting priorities is that the values and viewpoints of those involved in priority setting in health and social care will differ, and it is important to consider how these could be included to inform a priority setting process. The article concludes by proposing that principles and elements of process from each perspective could be brought together in a combined framework for use within local health and social care organizations.

Health and Social Care Spending and the Need to Set Priorities

It is well recognized that markets do not always work well in healthcare and hence some level of government intervention is required (Donaldson, 2011). However, government intervention and reforms, such as integration of health and social care, do not eliminate scarcity of resources and decisions around resource allocation still need to be made.

Frameworks for Priority Setting in Health and Social CareClick to view larger

Figure 1. Private and public healthcare expenditure by OEDC countries, U.S. dollars per capita, 2015 (OECD, 2017).

Note: “Government/compulsory” indicates financing through government spending and compulsory health insurance; “Voluntary” indicates voluntary health insurance and private funds such as out-of-pocket payments by households, NGOs, and private corporations.

According to the Organisation for Economic Co-operation and Development (OECD), the United Kingdom falls slightly above the median of OECD countries in terms of healthcare spending, and the majority of spending on healthcare comes from the public purse (Figure 1) (OECD, 2017). In 2015, total healthcare spending was £185 billion, with 79.7% financed from the government, up from £179.4 billion in 2014 with 79.5% financed from the government. This equates to 9.9% of gross domestic product (GDP). The growth rate between 2014 and 2015 was lower than between 2013 and 2014, 3.6% compared with 4.2% respectively. Therefore, although spending is increasing, it is doing so at a slower rate than in previous years.

Frameworks for Priority Setting in Health and Social CareClick to view larger

Figure 2. U.K. government healthcare expenditure by provider, 2015.

The majority of healthcare spending in the United Kingdom, shown in Figure 2, lies with the hospital sector, which received £71.4 billion of government money in 2015. This was followed by £35.8 billion to providers of ambulatory healthcare, which include GPs, dentists, and community health services.

Frameworks for Priority Setting in Health and Social Care

Figure 3. Spend on social care in England from 2009 to 2016 (data taken from Luchinskaya, Simpson, & Stoye, 2017).

In the United Kingdom, social care is funded through local authorities by way of taxation, with £29.9 billion spent nationally in 2016/2017 (Luchinskaya, Simpson, & Stoye, 2017). While spending on health has continued to increase (albeit at a lower rate), social care spending has fallen in England by 1% since 2009/2010 (Luchinskaya et al., 2017), as shown in Figure 3.The financial constraints around health and social care come at a time when these services are experiencing increased pressure. Demographic changes mean there is an increasingly older population in the United Kingdom (Office for National Statistics, 2015) with a greater prevalence of comorbidities (Department of Health, 2012). While at the national level, techniques exist to raise the quantity of resources available—for example, through increased taxation, increased borrowing, or by decreasing the public spend in other areas, such as defense—there is no “right” level of spending and choices will always need to be made about how available resources are allocated no matter what level the budget is set (Dixon, Harrison, & New, 1997).

To address some of the challenges of allocating scarce resources, different perspectives based on economics, decision analysis, ethics, and law have been advocated. This chapter summarizes each in turn.

Economic Perspective on Priority Setting

Economics is the study of how decisions to use scarce resources are made; as such, the discipline offers different techniques and tools that can be applied to priority setting (Mitton & Donaldson, 2004). At a national level, economic techniques such as cost-effectiveness analysis (CEA), cost-utility analysis (CUA), and cost-benefit analysis (CBA) are used in the public sector by national-level bodies. For example, the National Institute for Health and Care Excellence (NICE) in England uses CEA and CUA to assess the costs and benefits for the economic evaluation of new medical technologies. CEA measures benefits in terms of quantity of life or health gain, for example, life years gained or in natural units such as the amount of cholesterol reduction. CUA looks at benefits by combining the quantity of life gained with the health-related quality of that life using a measure called Quality Adjusted Life Year (QALY) (Drummond, Sculpher, Torrance, O’Brien, & Stoddart, 2005). The type of economic evaluation that is used will depend on the question to be answered. One type of question relates to technical efficiency. For instance: where a fixed amount of resources has been allocated to treat a condition, how do we best use those resources to maximize benefits? This question can be answered using CEA where the decision has been taken to treat a condition and we want to know the best way to do it. Another type of question relates to allocative efficiency, such as should we allocate more or fewer resources to an intervention? This question can be answered using CBA to look at achieving maximum health gain from total resources. However, CUA can be used to answer both types of question as it measures benefits of an intervention in QALYs, allowing interventions to be compared in terms of incremental cost per QALY ratios (Drummond et al., 2005).

However, the use of CUA and CEA for decision-making cannot always be replicated at the local level, where decisions about provision of health services for an entire population with a mix of different needs have to be made, not just recommendations for purchasing one technology at a time. The need to make difficult decisions is increased with the move toward the integration of adult health and social care services. Integration adds a level of complexity, as decisions now have to be made across both areas. Although this reduces the budgetary boundary between health and social care and has the potential to lead to greater efficiencies, it does require a culture change for health and social care staff to come together and agree on how decisions are made and resources allocated. For example, legislation in Scotland calls for local organizations to outline the process used to make resource-allocation decisions but does not outline what an appropriate priority setting process might look like, leaving those working at the local level to determine what framework or approach they should use.

Economic approaches to priority setting are underpinned by two key concepts: “opportunity cost” and “the margin” (Mitton & Donaldson, 2004). Opportunity cost refers to having to make choices on how resources are allocated within a fixed budget; certain opportunities will be taken up while others will not (i.e., allocating resources in one way means that they are not being allocated in a different way) (Mitton & Donaldson, 2004). The benefits (for example, improvement in quality of life or improvement in access to services) associated with opportunities not taken up are called opportunity costs. Thus, we need to know the costs and benefits from various healthcare activities. Marginal analysis is the assessment of costs and benefits “at the margin,” where the focus is on the benefit gained from an incremental increase in resources, or benefit lost from an incremental reduction in resources (Mitton & Donaldson, 2004). Generally, the application of economics focuses upon the balance of (in this context, health and social care) services, not necessarily the introduction or elimination of a service in totality, fitting with the agenda of shifting the balance of care from acute settings to the community. Essentially, this means starting by examining how resources are currently allocated and how potential changes in that mix could make the most of the resources available to maximize the benefits from the services provided.

Table 1. Using PBMA: Five Questions for Localized Priority-Setting Process

PBMA addresses priorities from the perspective of resources:

1.

What resources are available in total?

2.

In what ways are these resources currently spent?

3.

What are the main candidates for more resources and what would be their cost and effectiveness?

4.

Are there any areas of care within the program which could be provided to the same level of benefit but with fewer resources, so releasing those resources to fund candidates from (3)?

5.

Are there areas of care which, despite being effective, should have fewer resources because a proposal (or proposals) from (3) is (are) more effective for the resources spent?

Source: Mitton and Donaldson (2004).

A structured way to approach the planning of service delivery either at the program level (such as diabetes) or for a whole population is through using a generic framework. One such framework is Programme Budgeting and Marginal Analysis (PBMA). PBMA starts by asking five questions about resources, as shown in Table 1 (Mitton & Donaldson, 2004).Questions 1 and 2 involve presenting estimates of current expenditure and activity across (or within) “programs” of care or service delivery to make the Program Budget (PB). This allows the organization to know where it is in terms of resource allocation before deciding on any changes to this allocation. Questions 3–5 involve the evaluation of changes in the costs and consequences when resources are used in a different way; essentially, analyzing the effects of changing the balance of expenditure within a given budget (Mitton & Donaldson, 2004). Within a fixed budget, options for more resources (question 3) can be funded by taking resources from elsewhere (questions 4 and 5). Question 4 is one of technical efficiency, for example, achieving the same health outcome at less cost. This type of efficiency can be seen in the need for organizations to make “efficiency savings” each year and to limit variations in the provision of services or prescription of medicines. Question 5 deals with the more difficult question of allocative efficiency, for example, deciding to treat one group of patients over another to achieve a greater health outcome at the same cost. This may involve taking resources from some groups of patients to give to others.

Frameworks for Priority Setting in Health and Social CareClick to view larger

Figure 4. Project management of PBMA: the seven steps (adapted from Mitton, Dionne, Damji, Campbell, & Bryan, 2011).

Implementation of the above framework is challenging and relies on careful project management. Therefore, alongside the five questions, there are seven steps of project management as outlined in Figure 4. These provide a generic structure for decision makers to follow, with key activities for each step. The first step in a PBMA exercise is to determine the aim and scope of the decision-making activity. This can involve looking at the best way to invest resources across all programs in a health and social care organization, or determining how best to spend resources within a specific program defined, for example, by disease or locality. The second step is to determine membership of an Advisory Group; this will depend on the aim and scope of the project, but will likely be a mix of staff from different areas, and could include lay members. A key factor is to keep the size of the group manageable, but this would ultimately be determined by the organization.

Once the Advisory Group has been determined, the third step is to develop a program budget, outlining current activity and expenditure. This will include costs and staff numbers and the number of patients (if appropriate) who access the services in question. However, the level of detail will depend on the data available and the timeframe for collating it.

The Advisory Group should then determine a set of decision-making criteria which reflects the objectives and values of the organization and allows for the assessment of the benefits of options for investment and disinvestment (step four). The criteria could include: access to services, health outcomes, or reducing health inequalities. Each option can then be assessed against how well it performs against each criterion, allowing comparison of different options on broadly similar terms. Once defined and agreed, criteria are then weighted to determine their importance relative to each other. Criteria can be weighted by the Advisory Group, and, if appropriate, by a wider group of staff and members of the public.

The next step is to identify options for growth, by using fewer resources for the same output, and for reduction. Evidence from an array of available resources—for example, published literature, local evidence and data, and expert opinion—should be collated for each option. The evidence can be outlined to show how well it meets each criterion in, for example, a set of uniform business cases. In step 6 the Advisory Group then scores how well each option meets each criterion. To assess the options, one technique is the calculation of a weighted benefit score (WBS) which combines the criterion weights and the scores for each option. The cost for each option is then divided by the WBS to give a cost-per-benefit point, and the options are ranked in order of lowest cost-per-benefit point to highest. Other techniques can be used, but it is important to note that, in each, the participants can examine information on costs and benefits separately and account for the size of each option in budgetary terms.

The rankings are not set at this stage. Options can be moved up or down the list as agreed within the Advisory Group, and the reasons for doing so noted. Once rankings are agreed, the Advisory Group can then make formal recommendations on changes in use of resources. The final step is to validate and review the process.

In summary, the PBMA framework attempts to connect economic principles (opportunity cost and the margin) with a project management framework to provide a structured process. Notwithstanding substantial research undertaken on PBMA and priority setting in health (Bate, Donaldson, & Murtagh, 2007; Bate & Mitton, 2006; Gibson et al., 2006; Mitton, Dionne, Damji, Campbell, & Bryan, 2011; Mitton et al., 2013; Mortimer, 2010), and instances where it has been used in practice, in healthcare settings, it is not routinely applied to set priorities within organizations (Mitton & Donaldson, 2001). This research has documented the challenges of using PBMA and facilitated a substantial body of learning which can be applied in other settings. One of the challenges of using PBMA to set priorities is the need to create capacity within organizations for staff to complete the process alongside many other competing tasks: lack of capacity of those involved can affect the membership of the Advisory Group and lead to non-attendance at meetings, causing the process to stall. Additionally, gathering data to inform the program budget can be challenging, and will be more so when social care is considered within the process, as the data is not as well established as that for healthcare.

There is a need for researchers to understand the context in which decisions are made so as to provide a more detailed framework for priority setting; this may encourage the use of such a structured process. However, regardless of the amount of data or evidence available to make decisions, difficult decisions still need to be taken. The advantage of using a more structured process, like PBMA, is that it can facilitate more transparent decision-making and allow explicit comparisons to be made among different options for investment and disinvestment.

Within a PBMA process decision-making criteria need to be used to assess the benefits of options for change. As described above, these criteria should be weighted to show the importance of each criterion. One criticism is that the techniques incorporated within a PBMA approach to weight criteria are not particularly robust. One potential way to overcome this is to incorporate techniques from multi-criteria decision analysis (MCDA), as discussed in “Decision Analysis Perspective on Priority Setting” (Keeney & Raiffa, 1976).

Decision Analysis Perspective on Priority Setting

Table 2. The Main Steps of MCDA

1.

Defining the decision problem: describe the problem clearly, and validate and report it

2.

Selecting and structuring criteria: report and justify the methods to identify criteria and definitions

3.

Measuring performance: report and justify the sources used to measure performance and the performance matrix

4.

Scoring alternatives: report and justify the methods used for scoring

5.

Weighting criteria: report and justify the methods used for weighting

6.

Calculating aggregate scores: report and justify the aggregation function used

7.

Dealing with uncertainty: report sources of uncertainty and the uncertainty analysis

8.

Reporting and examining findings: report and examine the MCDA method and findings

Source: Adapted from Marsh et al. (2016).

Multi-criteria decision analysis (MCDA) is an approach originating in the Decision Sciences. MCDA seeks to support decision makers in using multiple criteria to make decisions, and it provides techniques for the weighting of criteria and scoring of options for change (Keeney & Raiffa, 1976). The criteria on which decisions are made need to be considered together, but not all criteria are equally important. The main aim of MCDA is to establish preferences between options based on a set of objectives that have been identified by the decision makers. The main steps of an MCDA process are outlined in Table 2.The first stage, as in Programme Budgeting and Marginal Analysis (PBMA), is to define the decision problem. This includes identifying and involving appropriate stakeholders to think about the alternatives that are under consideration.

Criteria can be identified in various ways from, for example: previous decisions, discussion with key stakeholders, or facilitated workshops. The criteria are the measures of performance by which the options will be judged, and must be selected to ensure completeness, feasibility, and mutual independence, without becoming too numerous to be manageable (Baltussen & Niessen, 2006).

Table 3. Example of a Performance Matrix

Option

Cost-effectiveness (US$ per DALY)

Severity of disease

Disease of the poor?

Affected age group

Antiretroviral treatment in HIV/AIDS

200

High

Yes

15 years and older

Treatment of childhood pneumonia

20

High

Yes

0–14 years

Inpatient care for acute schizophrenia

2000

Medium

No

15 years and older

Plastering for simple fractures

50

Low

No

All

Source: Adapted from Baltussen and Niessen (2006).

Note. DALY = disability-adjusted life year.

One standard feature of an MCDA process is a performance matrix. The purpose of the matrix is to show the performance of each alternative against each criterion (Marsh et al., 2016). For example, Table 3 shows a performance matrix for four options to treat different health conditions. The health conditions are compared in terms of cost-effectiveness, severity of disease, whether it is a disease of the poor, and the age of those affected by the condition (Baltussen & Niessen, 2006).In a performance matrix, the criteria are shown along the top of the table and the options in the first column. The performance matrix can be analyzed qualitatively by making comparisons of the options, for example, does one dominate on all criteria compared to others? Ranking the options in a qualitative way may be quick and effective when compared to quantitative techniques used to rank the options (Baltussen & Niessen, 2006).

As part of building a more quantitative model to evaluate options, the information in the matrix can be converted to a numerical value. The main idea here is to construct scales (0–100) representing preferences for the consequences, with 0 being the worst performance level and 100 the best. Then any remaining options need to be scored. To do this requires discussion of how the other options meet the criteria and where on the scale they would fall. To facilitate this, it is useful to draw scales and ask individuals to score each option and discuss the scores. Once the options are scored, the criteria are weighted, as we need to know the importance of each criterion.

Techniques for weighting criteria include: points allocation, analyst hierarchy process, discrete choice experiment, and swing weighting (Marsh, Lanitis, Neasham, Orfanos, & Caro, 2014). Swing weighting is a systematic and theoretically well-grounded technique for weighting criteria. A swing is an increase in performance of an option against a criterion from the worst to the best performance level, and a weight reflects the value of that swing. For example, in considering the options set out in Table 3, we could look at the swing from cost per DALY of US$2,000 to US$20 compared with a swing from high to low severity of disease. If the swing on severity of disease is preferred then this would be given a weight of 1 by the decision makers and cost-effectiveness would then be assigned a fraction of that weight, for example, 0.85 (again decided by those involved in the decision-making). This would be done for each criterion. Once the scores and weights have been decided by the group involved in making decisions, the scores are multiplied with the weight of the criterion and summed across criteria (Airoldi, Morton, Smith, & Bevan, 2014).

A critical element of the MCDA process is the use of sensitivity analysis to look at the impact on the ranking of options by changing the scores of the options or criteria weights. This can highlight where any uncertainty may have arisen, and the final ranking of the options can be altered if deemed appropriate by the decision makers.

There are tools and software which can aid organizations in using MCDA. One such tool, developed by the Health Foundation and the London School of Economics, is STAR—Socio-Technical Allocation of Resources (The Health Foundation, 2018). This includes a freely available spreadsheet and guide for local organizations. Recently, Public Health England launched a prioritization framework to help local authorities make spending decisions across public health programs. This is also based on MCDA and includes a spreadsheet and guidance on how to use the tool (Public Health England, 2018).

In summary, MCDA has been applied in public- and private-sector decisions, for example, transport, education, and environment. While it has had only a few applications to resource-allocation decisions in healthcare, this is on the rise (Diaby, Campbell, & Goeree, 2013). One issue with MCDA is that there are a number of different ways to put it into practice, so a lack of guidance on how to use it successfully for healthcare decisions can lead to misuse of the technique (Thokala et al., 2016). However, work has been undertaken by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) to establish a common definition for MCDA in healthcare decision-making and to develop good practice guidelines. Two reports were produced from this work (Marsh et al., 2016; Thokala et al., 2016). One aspect of MCDA that requires further deliberation is the need to consider budget constraints when using MCDA within decision-making in healthcare. A review of MCDAs (Marsh et al., 2014) to support healthcare decisions found that a cost criterion was included to deal with the issue of budget constraint. However, it is argued that this does not adequately capture the opportunity cost of alternatives (Claxton, 2015). Therefore, the forgone alternatives would need to be identified within the same MCDA framework to incorporate the opportunity costs (Marsh et al., 2016).

Ethico-Legal Perspective on Priority Setting

Programme Budgeting and Marginal Analysis (PBMA) and multi-criteria decision analysis (MCDA) map out a process for priority setting and certain key activities to assess different options for investment and disinvestment within the same framework, and it is clear how these two frameworks fit together given the use of multiple criteria in both. However, there is a need to understand other perspectives on priority setting to effectively defend investment and disinvestment decisions given that the goal of priority setting is not solely to maximize the benefits from the health services provided but may also be concerned with equity issues, such as looking to treat those in the greatest need or to reduce health inequalities. In bringing these perspectives together we can seek to make decisions based on a robust, fair, and transparent process while also assessing the impact of decisions made from such a process.

Table 4. Procedural Conditions of Accountability for Reasonableness

Condition

Description

(a) Ensure publicity for the priority-setting process

Make the priority-setting process and decisions, and the rationales behind them, accessible to stakeholders and the local population.

(b) Ensure relevance of the priority-setting process

The priority-setting process and resulting decisions should be based on principles, reasons, and evidence that stakeholders agree are relevant.

(c) Establish an appeals mechanism

The mechanism should allow people to challenge decisions within the prioritization process and should facilitate resolution of disputes, if necessary by revising decisions in light of further evidence.

(d) Establish an enforcement mechanism

There is voluntary or public regulation of the prioritization process and an appeals mechanism to ensure that the first three conditions are met.

Although equity issues can be incorporated within PBMA and MCDA as part of the criteria it is important to consider them in more detail due to their importance in health and social care organizations. Studies of societal values have shown that particular groups or patients, such as the most severely ill, are generally prioritized by respondents (Gu, Lancsar, Ghijben, Butler, & Donaldson, 2015; Nord & Johansen, 2014). This is also seen in the ethical literature on priority setting, where the formal principle of justice states that like cases ought to be treated alike and that unlike cases should be treated differently (Clark & Weale, 2012). The ethical issue raised is: what are like cases? Alongside these concerns are the need to consider processes for priority setting, and the values that should underpin these processes. Currently, there is a focus on approaches that are underpinned by concepts of fairness and procedural justice to ensure a robust process. One approach, where the procedural conditions are outlined, is called Accountability for Reasonableness (A4R), shown in Table 4 (Daniels & Sabin, 1998).These conditions of transparency, accountability, and participation provide the main grounding to ethical decisions in the context of priority setting. Similarly, from a legal standpoint, the main objective is procedural justice, and ensuring that decisions are based upon legally relevant criteria. To this end, courts provide an oversight role, and where challenges to priority setting decisions are made, they will closely scrutinize both the process used to make the decision and the application of the criteria by the organization; however, they usually remain reluctant (and lack the legal power) to challenge the outcome of the priority setting process. In this way, legal oversight can fulfill the enforcement condition of A4R and ensure the realization of the other conditions of the model (Syrett, 2007).

Equity is another aspect of priority setting, and the fairness of resource distribution should be considered. Thus trade-offs between efficiency and equity may be required. To determine the principles underpinning approaches to the allocation of resources it is widely accepted that the views and values of the general public should be accounted for as taxpayers and potential future beneficiaries (or not) of services and treatments. One approach to elicit societal values is through the use of preference elicitation techniques, such as willingness to pay (WTP), discrete choice experiments (DCE), or person trade-off (PTO). There are many examples of preference studies in the health literature: to value healthcare programs (Nord, 1995; Olsen & Donaldson, 1998) and the relative value of different types of QALYs (Pinto-Prades, Sanchez-Martinez, Corbacho, & Baker, 2014), and to develop priority setting frameworks (Watson, Carnon, Ryan, & Cox, 2011). A key feature of these techniques is that trade-offs are made between competing options which make explicit the notion of opportunity cost. However, the design of preference studies typically requires reducing the issues to a manageable number of attributes, and so hypothetical choices can be reductionist or focused on single issues, such as severity or rarity of disease, or age of patients. Therefore, economics methods to date do not account for wider issues such as those related to societal values.

A different type of approach which can enable a more holistic understanding of what is important to individuals in the area of resource-allocation decisions and, thus, enable decisions to be better defended, is Q methodology.

Q methodology, first described by the British physicist and psychologist William Stephenson in a letter to Nature in 1935, provides the basis for studying “subjectivity”—opinions, values, beliefs, and tastes (Stephenson, 1935; Stephenson, 1953). It is a mixed methodology combining qualitative and quantitative techniques to enable the identification and description of shared perspectives around a given topic (Baker, Wildman, Mason, & Donaldson, 2014; Watts & Stenner, 2012). The two main features of Q studies are a card-sort exercise to generate data and by-person factor analysis, which identifies patterns of similarity between card sorts. The methodology is well established and has been applied in several areas in psychology and in political, social, and environmental sciences (Brown, 1980; Cuppen, Breukers, Hisschemoller, & Bergsma, 2010; Jeffares & Skelcher, 2011; Stenner & Rodgers, 1998).

Table 5. Five Viewpoints to Guide Healthcare Priority Setting

Viewpoint

Title of Viewpoint

1.

Egalitarianism, entitlement, and equality of access

2.

Severity and the magnitude of health gains

3.

Fair innings, young people, and maximizing health benefits

4.

The intrinsic value of life and healthy living

5.

Quality of life is more important than simply staying alive

Note. See Van Exel, Baker, Mason, Donaldson, and Brouwer (2015) for a full description of these viewpoints.

In health research, Q methodology has been used in many ways, such as in exploring economic models of rationality (Baker, 2006) and attitudes around health lifestyles (Van Exel, De Graaf, & Brouwer, 2006). Of particular relevance to the subject of this article is its use to investigate issues around public priorities for healthcare provision (Baker, Bateman, et al., 2010; Mason, Baker, & Donaldson, 2011; McHugh et al., 2015; Van Exel, Baker, Mason, Donaldson, & Brouwer, 2015). For example, one study (Van Exel et al., 2015) used Q methodology to examine societal views on principles to guide priority setting in healthcare across ten countries (Denmark, France, Hungary, the Netherlands, Norway, Palestine, Poland, Spain, Sweden, and the United Kingdom). Five distinct, shared viewpoints were identified and labeled (see Table 5). Such studies can provide rich accounts of the multiple views which can be found within society. From these results it is also possible to develop Q-based survey design (Q2S) techniques that can be used to measure the prevalence of views described in a Q study. In a follow-up study, Q2S techniques were designed and applied to measure the extent to which the views identified by Van Exel et al. (2015), shown in Table 5, were held across nine of the ten countries (Mason et al., 2016). Here the Q2S approach involved developing short summary descriptions of the five viewpoints based on their most characterizing and distinguishing features, and then having respondents indicate their strength of agreement using a seven-point Likert scale; respondents were assigned to a viewpoint based on their highest score (Baker, Van Exel, Mason, & Stricklin, 2010; see Baker, Bateman, et al., 2010, for a discussion of other Q2S approaches). Analysis of Q2S responses found that Viewpoint 1—“Egalitarianism, Entitlement and Equality of Access”—had most support but was not a majority view in any of the countries.

Q methodology (and Q2S techniques) can enable shared societal viewpoints to be better represented in debates around priority setting, as they allow societal views (and those who hold them) to be identified and described. Accounting for societal values within or alongside a priority setting process is important, however: as the above example illustrates, it is likely that multiple shared viewpoints will emerge, so there is a question about how best to incorporate societal views into a priority setting process when people disagree. From an ethico-legal perspective, it is also necessary to consider whether views are unethical or unlawful before allowing them to inform priority setting. From a more pragmatic perspective, it is important to establish whether views are simply not practical, affordable, or operational in some other way. While further research and discussion are needed to explore these larger issues, presently, Q methodology has potential as a tool for committees to examine their own societal values and to compare the views represented by committee members with the views in the wider population. This might be of relevance for decision-making processes at a national level, for example, to identify individuals holding particular views to sit on NICE’s Citizens Council so that all societal views are represented. At a local level Q methodology could be used in parallel with other priority setting techniques to better understand the views of those involved in decision-making processes and have them reflect on their own values.

Conclusion

Decision makers within health and social care settings are constrained by scarce resources, increased demand on services, and the lack of systematic frameworks for the allocation of resources for commissioning that explicitly focus on trade-offs. While the integration of health and social care introduces complexities, it also represents a unique opportunity to think about and apply different perspectives and processes for priority setting. This chapter has outlined different perspectives (economics, decision analysis, ethics, and law) and approaches (Programme Budgeting and Marginal Analysis, PBMA; multi-criteria decision analysis, MCDA; and Q methodology) that, if combined, could represent a more structured and transparent framework for decision-making that would allow organizations to better defend themselves against any challenges made. Decisions are likely to be increasingly challenged as funding to health and social care organizations is increasingly being squeezed, and decisions to disinvest in services may increase.

PBMA is based on similar principles to those that underpin economic evaluation and is an example of a priority setting process where investment and disinvestment options are identified and evaluated using multiple criteria, and ranked accordingly, in a manner which allows for the consideration of opportunity costs. MCDA is a technique originating in the Decision Sciences which provides a more robust approach for considering multiple criteria involved within a PBMA process and can help guide decision makers in a local context. Yet the processes adopted by PBMA and MCDA are generally not used together.

In addition, it is also important that priority setting frameworks consider the need for decisions to be defended both ethically and legally. Defending decisions, particularly to people who do not have certain expertise—for example, a health service or social care background—requires being able to point to a robust decision-making process. From an ethical point of view, the focus has been on developing conditions that provide a fair and robust decision-making process, as outlined in Accountability for Reasonableness (A4R). If the four conditions of A4R are met then it is argued that the decisions reached are legitimate and fair. Similarly, from a legal perspective, where a challenge to a decision is made, the court will review the fairness and transparency of the process for making the decision and whether it was based upon relevant criteria.

There is also a need to understand the values and views of decision makers and members of the public who access health and social care services, and then to incorporate these in a priority setting process. Q methodology and associated survey methods offer a way to gain insight into the shared societal perspectives that exist around priority setting, and to identify those who hold such perspectives. One way forward is to use Q methodology to inform aspects of PBMA and MCDA processes, or potentially to combine these different methods into a single framework to be used within this newly integrated health and social care environment. For example, Q methodology could be used to inform the issue of allocative efficiency (Question 5) within a PBMA framework with societal views regarding the allocation of scarce healthcare resources. A combination of approaches could result in a more robust process for decision-making, where the views and values of those involved in decision-making at a local level and those affected by decisions are also incorporated.

In summary, a combined framework would draw upon the principles outlined from each perspective: the economic principle of opportunity cost, where resources can be allocated only once; decision analysis for assistance in making good decisions and for techniques for weighting criteria and scoring options; the main ethical principle of justice and how this is accounted for in the process; and, from law, the aim of working toward a fair and defensible process. In addition to being underpinned by these principles, different empirical approaches from the processes of PBMA, MCDA, ethics, and law can be incorporated within the combined framework; for example, looking at current resource use for a program of care (PBMA), using techniques used in MCDA for weighting criteria, and incorporating the card-sort exercise from Q methodology to address broader issues of societal values (i.e., what do people want to count).

The integration agenda for health and social care is an opportunity to develop and implement a combined and systematic framework based on several disciplines and approaches for the common purpose of sustaining publicly funded services whilst ensuring they meet the needs of the population fairly. It is hoped that the matters explored in this article will provide a basis for development in this direction.

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